e21CHAPTER 136 Board Review Questions 2 A 10 month old unrestrained child who is a victim of a motor vehicle crash is admitted to your PICU The child has sus tained significant intracranial injury wit[.]
CHAPTER 136 Board Review Questions A 10-month-old unrestrained child who is a victim of a motor vehicle crash is admitted to your PICU The child has sustained significant intracranial injury with subdural blood noted on the initial computed axial tomography scan of the head The neurosurgical team has indicated that no surgical intervention is required at this time This child has a Glasgow Coma Score of No sedation or analgesia has been administered for the past hours The child is endotracheally intubated and mechanically ventilated with fraction of inspired oxygen (Fio2), 0.8; peak inspiratory pressure, 30 cm H2O; positive end expiratory pressure, 10 cm H2O; ventilator rate, 22 breaths per minute The chest radiographs show bilateral pulmonary contusions Agonal respirations noted 24 hours ago have ceased Blood pressure is being supported with an epinephrine infusion of 0.7 mg/kg/min Urine output has remained acceptable since admission days ago The bedside nurse notifies you that the child has fixed and dilated pupils Which of the following statements is most correct? A Ancillary studies are not required to make the diagnosis of neurologic death in infants younger than one year of age B An observation period of 24 hours between neurologic examinations is recommended to determine neurologic death in this patient C The partial pressure of carbon dioxide (Paco2) of 59 mm Hg during the apnea exam is sufficient to confirm brain death D Two separate examinations and a single apnea test are required to determine neurologic death in infants and children Preferred response: A Rationale Determination of neurologic death is a clinical diagnosis that relies on the neurologic examination and an apnea test Neurologic death can be determined in term infant 37 weeks estimated gestational age (EGA) to 30 days of age to 18 years of age It can be more difficult to make a determination of neurologic death in the neonate and younger child; therefore, serial examinations are essential to ensure the clinical examination remains consistent throughout the observation and testing period The recommended observation period for infants 37 weeks EGA to 30 days of age is 24 hours A 12-hour observation period is recommended for children older than 30 days of age Apnea testing must be performed with each examination, and the Paco2 must rise to 60 mm Hg and 20 mm Hg above the baseline Paco2 for the apnea test to be valid by current national guidelines Ancillary studies are not required to make a determination of neurologic death in any patient of any age unless the clinical examination and apnea test cannot be completed, making choice A the correct response e21 You have been asked by the organ procurement organization to assist with management of a 4-year-old child This patient has been declared dead by neurologic criteria, and the parents have authorized donation This patient has required extensive fluid resuscitation for blood pressure support The child continues to receive vasopressor support with an epinephrine infusion of 0.6 mg/kg/min and dopamine of 12 mg/kg/min Mechanical ventilation is instituted as follows: fraction of inspired oxygen (Fio2), 0.65; peak inspiratory pressure, 28 cm H2O; positive end expiratory pressure, 12 cm H2O; ventilator rate, 22 breaths per minute Laboratory evaluation reveals: hemoglobin, 7.6 g/dL; hematocrit, 22.3%; serum sodium, 162 mEq/L; potassium, 3.1 mEq/L; chloride, 119 mEq/L; blood urea nitrogen (BUN), 19 mg/dL; creatinine, 1.2 mg/dL Which of the following statements is correct? A Corticosteroids can stabilize lung function and reduce free water accumulation in a donor B Desmopressin for treatment of diabetes insipidus can improve blood pressure and potentially reduce vasopressor requirements in a donor C Intranasal vasopressin is the preferred treatment for diabetes insipidus in a donor D Thyroid hormone prevents the anaerobic to aerobic cellular metabolic shift in a donor Preferred response: A Rationale Hormonal replacement therapy (HRT) restores aerobic metabolism, replaces hormone derived from the hypothalamus and pituitary, augments blood volume, and minimizes the use of inotropic support while optimizing cardiac output Common agents used for HRT include thyroid hormone, corticosteroids, and vasopressin or desmopressin for treatment of diabetes insipidus Corticosteroids such as hydrocortisone are another pharmacologic agent routinely used by many centers for HRT to assist with hemodynamic support Treatment of the donor with high doses of corticosteroids reduces inflammation associated with neurologic death and modulates immune function The potential benefit of hydrocortisone and other steroids may lie in their ability to alter adrenergic receptors and regulate vascular tone by increasing sensitivity to catecholamines Steroids have also been shown to stabilize pulmonary function, reduce lung water accumulation, and increase lung recovery from donors, making A the correct response The effects of thyroid hormone on myocardial contractility can be immediate or delayed Thyroid hormone is commonly used in the hemodynamically unstable donors The acute inotropic properties of thyroid hormone may occur as a result of beta-adrenoreceptor sensitization Additionally, thyroid hormone administration may play an important role in maintaining aerobic metabolism at the tissue level after neurologic death has occurred Levothyroxine (Synthroid) and triiodothyronine (T3) are the two intravenous thyroid agents available for administration Vasopressin is commonly used to treat diabetes insipidus (DI) in the donor This agent is not as potent as desmopressin on a weight per weight basis Use of vasopressin for treatment of DI can reduce the need for vasopressor support Vasopressin and desmopressin should be administered by the intravenous route Intranasal administration is not recommended because of erratic or no absorption in the brain-dead donor e22 S E C T I O N XV Pediatric Critical Care: Board Review Questions You are caring for a critically ill 15-month-old patient who was a victim of abusive head trauma admitted to your PICU days ago This child is comatose with a Glasgow Coma Score of 3, fixed and dilated pupils, and no response to noxious stimulation The child is mechanically ventilated with the following settings: fraction of inspired oxygen (Fio2), 1.0; peak inspiratory pressure, 32 cm H2O; positive end expiratory pressure, cm H2O Blood pressure is being supported with an epinephrine infusion of 0.9 mg/kg/min, and 15 mg/kg/min of dopamine The child has a markedly distended abdomen and has minimal urine output A chest radiograph revealed posterior and lateral rib fractures and bilateral pleural effusions with a right upper lobe consolidation Computed tomography scan of the head revealed bilateral subdural and subarachnoid hemorrhages, diffuse cerebral edema, and effacement of the lateral ventricles Serum laboratory studies revealed white blood cell count, 10.6 103/µL; hemoglobin 7.8 g/dL; hematocrit, 24.2%; sodium, 157 mEq/L; potassium, 4.1 mEq/L; chloride, 116 mEq/L; bicarbonate, 16 mEq/L, blood urea nitrogen, 24 mg/dL; creatinine, 1.92 mg/dL; glucose, 136 mmol/L; lactate, 4.3 mg/dL; alanine aminotransferase, 93 U/L; aspartate aminotransferase,126 U/L; albumin, 2.6 g/dL; protein, 4.1 g/dL; prothrombin time (PT), 15 seconds; international normalized ration (INR), 1.6; activated partial thromboplastin time (aPTT), 62 seconds Arterial blood gas revealed pH, 7.392; partial pressure of carbon dioxide (Paco2), 30 mm Hg; partial pressure of oxygen (Pao2), 83 mm Hg; bicarbonate, 18 mEq/L; base excess, 25 mmol/L Which of the following statements is correct? A Early referral of the organ procurement organization after neurologic death has been declared can enhance chances for organ recovery B Maintenance of euvolemia and correction of metabolic derangements will have little effect on graft function and viability of organs for transplantation C Notifying the medical examiner or coroner’s office prior to death may expedite and facilitate organ donation D Organ donation is not possible because of multisystem organ dysfunction Preferred response: C Rationale Involvement of the pediatric intensivist and critical care team in the management of critically ill and injured children, especially in pediatric donation, where there is a limited and decreasing number of donors improves the quality and number of organs recovered Preconceptions about eligibility for donation by the critical care team may not be current or accurate Donor organ suitability for transplantation is best assessed by the organ procurement organization (OPO) Thresholds for acceptable organ dysfunction can vary according to time of evaluation, transplant program comfort levels, and recipient urgency In many instances management of the potential organ donor can improve organ function and increase chances of successful organ recovery Serial echocardiograms may demonstrate donor response to effective medical therapy enabling cardiac recovery for transplantation; a positive blood culture or bacterial meningitis may not preclude organ donation if antibiotic therapy has been administered Organs from HIV positive donors can be transplanted into HIV-positive recipients, and organs from hepatitis positive donors are now being transplanted with good success Successful recovery of organs and the prosecution of the perpetrator may still occur in most cases of child homicide with close cooperation between forensic investigators, treating physicians, the transplant team, and OPO Early involvement of the medical examiner or coroner prior to determination of death and protocols to facilitate organ recovery in homicide cases may reduce denials for organ donation, making answer C the correct choice Efforts to reduce the number of medical examiner denials for donation are supported in the position statement by the National Association of Medical Examiners Early involvement and timely notification of the OPO prior to determination of death allows a greater amount of time for collaboration to coordinate the donation process Notification of the OPO after determination of death is considered a late referral and may not allow adequate time for the OPO and critical care team to fully discuss donation opportunities The OPO can also work closely with the medical examiner or coroner to facilitate donation in cases of homicide Ensuring OPO engagement early in the course of caring for a critically ill patient allows the intensive care team to better understand the entire donation process and eliminate confusion that may disrupt end-of-life care and the process of donation Early referral improves authorization rates and can assist families with understanding and coping with end-of-life care issues Which of the following substances is markedly elevated immediately following brain death: A Antidiuretic hormone B Catecholamines C Cortisol D Insulin E Thyroid hormone Preferred response: B Rationale Neurologic death resulting from cerebral ischemia increases circulating cytokines, reduces cortisol production, and precipitates massive catecholamine release Hemodynamic deterioration associated with neurologic death is initiated by a massive release of catecholamines, commonly referred to as sympathetic, catecholamine, or autonomic storm The sympathetic storm results in intense but transient hypertension The tremendous physiologic derangements associated with neuroendocrine dysfunction require specific interventions to restore normal physiology Agents such as thyroid hormone, corticosteroids, vasopressin, and insulin are commonly employed during donor management Hormonal replacement therapy can reduce circulatory instability associated with thyroid and cortisol depletion, especially in situations where significant inotropic support is required Which of the following metabolic derangements is common following neurologic death? A Hypercalcemia B Hyperglycemia C Hypermagnesemia D Hypochloremia E Hyponatremia Preferred response: B CHAPTER 136 Board Review Questions Rationale The critical care team should actively manage the potential donor and correct existing physiologic and metabolic derangements that follow neurologic death to preserve the option of organ donation for the family Metabolic derangements such as iatrogenic hypernatremia from hyperosmolar therapy and hyperglycemia associated with catecholamine release and reduced cerebral metabolism should be corrected Volume loss from osmotic diuresis associated with hyperglycemia and diabetes insipidus (DI) following neurologic death must be anticipated and addressed to prevent cardiovascular collapse Without substrate consumption by the brain, glucose needs are reduced, and the patient is prone to hyperglycemia As neurologic death occurs, cerebral metabolism is further decreased and co2 production falls resulting in a reduction in Paco2 Hypothermia should be anticipated as a result of hypothalamic failure and loss of thermoregulation Additionally, impaired adrenergic stimulation results in loss of vascular tone with systemic vasodilation and amplified heat losses Hypocalcemia occurs commonly secondary to large volume replacement with colloids such as albumin, massive blood transfusions that result in large amounts of citrate reducing free calcium concentrations, and sepsis Calcium is necessary for myocardial contraction and hypocalcemia can depress cardiac output, affect SVR, and organ perfusion The use of calcium supplementation should be guided by ionized calcium levels Evaluation of a 3-year-old child for brain death is being considered To determine brain death in this child, which of the following is most accurate? A A longer period of observation in this young child is required because of legal issues B An ancillary study is required to make the diagnosis of brain death in children C Ancillary studies such as electroencephalogram, radionuclide cerebral blood flow study, and computed tomography angiography are used in children D A thorough neurologic examination and apnea test are required to make the diagnosis of brain death Preferred response: D Rationale In a child older than year, brain death is a clinical diagnosis and does not require an ancillary study unless the examination and apnea test cannot be completed A thorough neurologic examination and apnea test that is repeated after a specified observation period is required to determine brain death based on clinical criteria A longer observation period is currently recommended in infants younger than 30 days and for children younger than year For children older than year, an observation period of 12 hours is recommended Ancillary studies such as an electroencephalogram and cerebral blood flow study can be used to assist with the diagnosis of brain death Computed tomography angiography has not been validated in children and cannot be relied on as a diagnostic ancillary test to determine brain death in children The apnea test must achieve a Pco2 of 60 mm Hg to be consistent with brain death e23 Which statement about neurologic death in infants and children is true? A Ancillary studies are required to make the diagnosis of neurologic death in infants younger than year of age B A Paco2 of 59 mm Hg in a child with acute lung injury who desaturates minutes into the apnea exam is consistent with brain death C Neurologic death can be determined in term newborns at 37 weeks’ estimated gestational age D The revised pediatric brain death guidelines require two separate examinations and a single apnea test to determine neurologic death in infants and children Preferred response: C Rationale Determination of neurologic death can occur in a term infant at 37 weeks’ estimated gestational age (EGA) to 30 days of age It can be more difficult to make a determination of neurologic death in the neonate; therefore serial examinations are essential to ensure that the clinical examination remains consistent throughout the observation and testing period The recommended observation period for infants at 37 weeks’ EGA to 30 days of age is 24 hours Apnea testing must be performed with each examination, and the Paco2 must rise to 60 mm Hg and 20 mm Hg above the baseline Paco2 to document apnea Two neurologic examinations and apnea tests separated by an observation period are required to establish the diagnosis of neurologic death in the United States The duration of observation between examinations is based on age Ancillary studies are not mandatory to make a determination of neurologic death The physician caring for the child will determine the need for ancillary studies based on history and the ability to complete the clinical examination and apnea testing If clinical examination and apnea testing cannot be safely completed, an ancillary study should be used to assist with determination of death Chapter 21: Long-Term Outcomes following Critical Illness in Children How does health-related quality of life (HRQL) differ from quality of life? A Consideration of entirety of past medical history for HRQL B Dimension of personal judgment over one’s health and disease C Inclusion of functional status during assessment of HRQL D Utilization of prospective as opposed to retrospective evaluation Preferred response: B Rationale Quality of life is defined as an individual’s perception of his or her position in life in relation to the individual’s goals, expectations, standards, and concerns HRQL is defined as quality of life in which a dimension of personal judgment over one’s health and disease is added, and encompasses the impact of health status on physical, mental, emotional, and social functioning e24 S E C T I O N XV Pediatric Critical Care: Board Review Questions A group of investigators is designing an interventional trial and planning to utilize health-related quality of life (HRQL) as the primary endpoint Which of the following protocol elements would optimize assessment for this outcome measure? A Ascertain baseline medical complexity for chronic comorbid conditions B Conduct paired baseline and follow-up HRQL surveys C Control for duration of intensive care unit stay D Undertake illness severity measures (e.g., PRISM, PIM) of all patient participants Preferred response: B Rationale Conducting paired HRQL assessments controls for each subject’s baseline status and permits change from baseline (paired) analyses Semi-quantification of baseline chronic comorbid conditions represents an alternative but less specific approach Which of the following represents a risk factor for prolonged deterioration of functional status from baseline following pediatric critical illness? A Duration of stay 28 days B Elective PICU admission C Nononcologic diagnoses D Younger age at PICU admission Preferred response: A Rationale Longer duration of PICU stay, oncologic diagnoses, older age, and emergent PICU admission are all risk factors for prolonged deterioration of functional status assessed by Pediatric Overall Performance Category Which of the following adverse events was most commonly documented among a cohort of children surviving critical illness at a median follow-up time of months after PICU discharge? A Fatigue disorder B Post-traumatic stress disorder C Psychiatric disorders D Sleep disorder Preferred response: D Rationale One study found that at a median of months after discharge, 20% of PICU survivors were at risk for psychiatric disorders, 34% were at risk for PTSD, 38% were at risk for fatigue disorder, and 80% were at risk for a sleep disorder Chapter 22: Burnout and Resiliency Which of the following is a common characteristic of compassion fatigue? A Alcohol use B Low energy in the workplace C Reduced capacity for empathy D Unrelieved stress and tension Preferred response: C Rationale Compassion fatigue is broadly defined as reduced capacity and interest in being empathetic for those who are suffering Although often used interchangeably, burnout consists of three dimensions including depersonalization, emotional exhaustion, and diminished feelings of personal accomplishment While compassion fatigue may result in burnout, they are not synonymous Low energy in the workplace, unrelieved stress and tension, and alcohol use may all contribute to or be signs or symptoms of burnout; none is specific to define compassion fatigue Which of the following factors has been found to be significant in the development of burnout among pediatric critical care physicians? A Female gender B Older age of a practitioner C Presence of a palliative care consult team D Years in pediatric critical care practice Preferred response: A Rationale A recent national cross-sectional online survey exploring burnout and psychological distress among over 250 pediatric critical care physicians in the United States found that the risk of any burnout was about two times more in women physicians (odds ratio, 1.97; 95% CI, 1.2–3.4) Association between other personal or practice characteristics and burnout was not evident in the study, while regular physical exercise appeared to be protective Which of the following measures is considered a successful organizational strategy for mitigating burnout in critical care providers? A Administering annual staff satisfaction surveys B Increasing helpful pop-up alerts within the EMR C Limiting family visitation hours D Using ethics and palliative care consultations in the ICU Preferred response: D Rationale The Critical Care Societies Collaborative’s Call to Action to address burnout identified that ethics and palliative care consultations is a successful strategy to mitigate burnout by divesting some of the burden of end-of-life discussions to clinical experts Additionally, providing healthy food options for clinicians, providing an on-site gymnasium, and offering stress-reduction courses are all considered to be useful for mitigating burnout in critical care providers What factor most specifically impacts the development of burnout in pediatric critical care providers? A Dealing with dying children B ICU shift length C Open visitation in the pediatric ICU D Pediatric resident and fellow rotation schedules Preferred response: A Rationale Dealing with the death of a critically ill pediatric patient has been demonstrated to be a specific factor impacting the development of burnout in pediatric critical care providers compared to general ICU related factors CHAPTER 136 Board Review Questions Chapter 23: Structure and Function of the Heart When examining a cardiac pathology specimen, atrial anatomy is defined by: A The venous return to the heart (typically the inferior vena cava or IVC, superior vena cava or SVC, and coronary sinus to the right atrium and pulmonary veins to the left atrium), the sinus node as a right atrial structure, and the atrial relationship to the atrioventricular (tricuspid or mitral) valves B The constant defining features of a right versus left atrium are the atrial appendage and its extent of pectinate muscles and the venous return to the heart (IVC, SVC, and coronary sinus to the right atrium and pulmonary veins to the left atrium) C The constant defining features of a right versus left atrium are the atrial appendage and its extent of pectinate muscles and typically the venous return to the heart (IVC, SVC, and coronary sinus to the right atrium and pulmonary veins to the left atrium) D Pulmonary venous return, a broad based atrial appendage, and sinus node as constant features of a right atrium Preferred response: C Rationale Ventricular morphology is defined by the atrioventricular (AV) valve it contains; however, the atria are not always related to the same sided AV valve (i.e., AV discordance), making answer A incorrect Systemic venous return is typically to the right atrium and pulmonary venous return to the left atrium, but not always, making answer B incorrect Answer D is also incorrect, since pulmonary venous return is typically a feature of the left atrium Which statement is true regarding the transition from fetal to postnatal circulation? A Compared to an infant at weeks of age, the infant at birth relies mostly on stroke volume in order to have adequate cardiac output B The ductus arteriosus is kept open in fetal circulation by a balance between prostaglandin E2 (PGE2) and endothelin-1 (ET-1) After birth, the vasoconstrictive effects of PGE2 become more dominant and the ductus constricts, leading to closure of the ductus within 24 hours to weeks C There is a significant decrease in total body oxygen consumption and cardiac output after birth Over time, with increased distensibility of the ventricular myocardium, the infant relies less on heart rate to augment cardiac output D With cord clamping, the baby experiences a rise in systemic vascular resistance (SVR) and a reduction in pulmonary vascular resistance (PVR) Preferred response: D Rationale During transition to postnatal circulation, there is a rise in SVR and a reduction in PVR, and there is a significant increase in total body oxygen consumption and cardiac output, which initially is heavily reliant on heart rate to increase output until ventricular distensibility improves Cardiac output in the fetus is determined mainly by heart rate because of a limited capacity to increase stroke volume that results mainly from decreased diastolic distensibility Consequently, fetal bradycardia is detrimental to blood flow and e25 oxygen delivery In addition, because at birth approximately 80% of the infant’s hemoglobin is in the form of fetal hemoglobin, the reduced ability of this hemoglobin to unload oxygen at the tissue level compels the infant to have a higher cardiac output than the infant will have to weeks later Therefore the neonate has limited cardiac output reserve, and the heart has near-maximal contractility These features make the neonate unusually susceptible to diseases that impair cardiac function When assessing a child with cardiomyopathy who has left ventricular dilation and moderate mitral regurgitation, the preferred method to evaluate and monitor systolic function via echocardiography is: A Change in ventricular pressure during isovolemic contraction before the aortic valve opens (dP/dT), taken from a continuous wave Doppler of the mitral regurgitation jet B M-mode derived TAPSE (tricuspid annular plane systolic excursion) C M-mode generated ejection fraction D No reliable echocardiographic method is available, and this patient should undergo cardiac MRI for functional assessments Preferred response: A Rationale TAPSE (tricuspid annular plane systolic excursion) is used to assess right ventricular systolic function (answer B is incorrect) Although an M-mode generated ejection fraction is a popular and common method used to assess systolic function in children, it is less accurate in the context of mitral regurgitation and left ventricular (LV) dilation (answer C is incorrect) Although cardiac MRI is useful for obtaining accurate chamber volumes and measures of systolic function, echocardiography is more practical and remains an accurate method for noninvasive regular surveillance of ventricular systolic function (answer D is incorrect) In the context of LV dilation and mitral valve regurgitation (MR), dP/dT (rate of pressure change over time during isovolumic contraction) is an accurate method of monitoring ongoing changes in contractility and is relatively unaffected by preload changes However, the clinician must keep in mind that dP/dT is affected by changes in afterload Therefore, in the context of heart failure therapy with afterload reducing agents, changes in dP/dT measurements of systolic function will need to be considered in this clinical setting Which statement is true in the context of reduced left ventricular contractility? A Due to the steep slope of the ventricular elastance line, small changes in afterload result in large increases in stroke volume and decreases in end diastolic pressure and volume B In order to eject a normal stroke volume, even in the face of a normal afterload, the ventricle compensates by increasing end diastolic volume C In order to maintain stroke volume and cardiac output, afterload is increased D In order to keep ejecting the same stroke volume, preload reserve is maintained during periods of increased afterload Preferred response: B Rationale See Figure 136.1 With decreased LV contractility, the ventricle compensates by increasing end diastolic volume (EDV) in order to maintain a normal stroke volume (answer B is correct) A higher afterload causes even further increases in EDV and EDP, ... death is being considered To determine brain death in this child, which of the following is most accurate? A A longer period of observation in this young child is required because of legal issues... annual staff satisfaction surveys B Increasing helpful pop-up alerts within the EMR C Limiting family visitation hours D Using ethics and palliative care consultations in the ICU Preferred response:... as the primary endpoint Which of the following protocol elements would optimize assessment for this outcome measure? A Ascertain baseline medical complexity for chronic comorbid conditions B